Cisepride, Ranitidine and Domperidone as prokinetics

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Mark Rowland — Mon, 05 Dec 2011 16:49:11 GMT

[quote user="Marie Kubiak"]Even if you do not agree with other people's practice sometimes it pays to keep an open mind rather than reject ideas immediately.[/quote]

Nice point, if a little patronising. One aspect of keeping an open mind is to present all the facts. It is interesting to note how you neglected to mention the other group of 137 rabbits in this trial. I wonder what the incidence of ulceration in this group was. I would expect at 7% possibly 9 or ten rabbits.

In fact the incidence was zero... 0%

This group was made up of rabbits bred for meat and breeding purposes.

So what of the ones with "ulceration"? 53 of the rabbits had fundic "ulcers" 15 of which were examined histologically. Barely any tissue reaction was seen with 0% extending to the muscularis. Heres a quote from a communication with Robert Schmidt a well respected zoo and exotic animal pathologist with a zoo/exotic pathology service in the states and 35 years experience of exotic pme's

"If the dx is post-mortem, the lesion is almost always post-mortem change. Rabbits seem to have a propensity for the stomach to dilate and in some cases actually rupture post-mortem. I'm not aware of any study, and have not see, ante-mortem gastric biopsies indicating any sort of stress-ulcer/erosion problem in rabbits"

No tissue reaction suggests post mortem change.

In the perforated pyloric ulcers, most were females in late pregnancy suggesting that this isolated group may be more at risk (I dont think anyone would be giving them metacam anyway).

So what do we learn from this study.

Well rabbits with chronic or terminal disease may be more at risk (a bit of a no brainer really) from ulceration. I think this is an of their sensitivity to steroids with stress contributing to endogenous steroid release. Pregnant does would fall into a similar category.

Do I think rabbits in general are ulcer sensitive?... no.

When I give talks, I say that birds are steroid sensitive as are rabbits so the listener should avoid these drugs in this species. I also say that rabbits are sensitive to dysbiosis so should not be given some antibiotics orally.

I see no reason to stop giving NSAIDs like metacam to anorexic rabbits as long as they are well hydrated. I do not believe they are ulcer sensitive. I think they are undergoing post mortem changes with minimal ulceration. Another quote:

Karen Rosenthal (well respected Exotic author)

"I do not see ulcers as a common or even infrequent disease in pet rabbits. I have been fortunate to work at two hospitals with necropsy service that was no charge to clients which allowed for investigation into many cases."

Im more than aware of the potential for ulcer formation in chronically ill rabbits which is why I give lots of fluids to ensure hydration and blood test for renal issues in older buns.

But "ulcer sensitive species" Nahh

Hope thats open minded enough.

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Mark Hedberg — Sat, 03 Dec 2011 14:42:02 GMT

Oral cisapride is available from summit pharmaceuticals.

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Gillian Mostyn — Wed, 30 Nov 2011 22:39:47 GMT

no - front leg. I don't use ear veins as I can't keep them in!

It's only the same as getting it in a 2kg cat really....not that difficult in most cases.

Re: Cisepride, Ranitidine and Domperidone as prokinetics

David Mills — Wed, 30 Nov 2011 21:04:03 GMT

[quote user="Gillian Mostyn"]

continuous infusion. I only give a bolus if the bunny is being naughty and keeps chewing the drip line - happens occasionally. I do start on quite a high rate (shock dose) for the 1st hour in severe cases.

[/quote]

Any tips for keeping them in?

We only see a few a year and they always seem to pull them out (perhaps they are too well to have them in). Using a yellow catheter and ear vein?

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Marie Kubiak — Wed, 30 Nov 2011 20:54:22 GMT

Sorry, couldn't immediately leap to action as have had 2 days of full surgery lists and no time to eat/breathe let alone dredge the annals of my laptop for info on this

7.3% of rabbit p-m cases have gastric ulceration with 50% of these cases having an identified primary pathology believed to predispose to ulceration (Gastric ulceration in the rabbit, Journal of comparative pathology, Vol 90, issue 3, July 1980, 475-481)

Adrenaline triggering gastric ulcer formation in rabbits has been clearly demonstrated in the experimental situation. Ill rabbits in an unfamiliar situation will be under catecholamine influence. Cimetidine was not found to eliminate ulcers once established. (Histology of experimental stress ulcer: the effect of cimetidine on adrenaline induced gastric lesions in the rabbit, J Experimental Pathology 1981 Aug;62(4):411-8)

Rabbits have COX-2 mRNA in their gastric mucosa which is inhibited by NSAIDs acting on COX-2 (such as meloxicam). (Constitutive Cycolooxygenase-2 expression in healthy human and rabbit gastric mucosa,Molecular pharmacology, Sept 1 1998 Vol 54, 536-540)

I view this as supportive of rabbits being capable of responding negatively to meloxicam with gastric ulceration as a potential consequence, and stress, failure of oral intake to dilute gastric acid, concurrent disease and gastrointestinal hypomotility as other risk factors. I'm not saying all rabbits in stasis will get ulcers but it is something I consider and use preventative medication where I feel appropriate.

Even if you do not agree with other people's practice sometimes it pays to keep an open mind rather than reject ideas immediately. I wouldn't be advocating NSAIDs in a cat/dog/ferret with gastrointestinal symptoms so exercise caution with rabbits too but am not forcing anyone to follow this. For rabbits with a normally functioning GI tract then I am comfortable giving NSAIDs without prophylaxis.

Marie

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Mark Rowland — Tue, 29 Nov 2011 20:27:33 GMT

So no then. No retrospective studies. No live studies

Richard cites Chronic disorders with no studies to back himself up (could have been due to renal failure)

Frances says it Can develop but is hard to diagnose with no studies to back herself up.

And on that basis you say rabbits are an ulcer sensitive species.

I assume then you give a nice low dose of metacam to your rabbit patients or do you concurrently routinely give ranitidine and risk dysbiosis

I think again, we may have to agree to disagree.

Ive anecdotally done lots of rabbit pms with histo and as I stated above those that had ulceration showed no signs of inflammation so could well have been agonal.

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Marie Kubiak — Tue, 29 Nov 2011 19:41:45 GMT

See Richard Saunders' excellent book, Notes on Rabbit Internal Medicine, "Gastric ulceration is a common complication in any chronic GI disorder".

Also FHB's review of treatment of the anorexic rabbit describing treatment of delayed GI emptying: "Gastric ulceration can develop and is impossible to diagnose with certainty so anti-ulcer medication, such as ranitidine is a good idea".

From spending far too much time in exotics path labs over the last few years I can also (anecdotally) confirm that many rabbits (and GPs) with a variety of primary diseases have secondary gastric erosions and ulceration and I would rather prevent this happening with my nice live cases where possible.

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Mark Rowland — Tue, 29 Nov 2011 17:47:09 GMT

[quote user="Marie Kubiak"]

ulcer-sensitive species .

[/quote]

???

Where is the paper that says this? Rabbits have the highest basal acid output among animal species studied. I dont think that being senstive to ulcers quite fits.

Gastric ulcers can be experimentally induced in rabbits, but from what I read, experimental induction involves chemical burns to gastric mucosa - I don't know if this relates or is comparable to what we might see in a pet rabbit.

Histo I have done on pm samples of rabbit ulcers have shown no imflammation, suggesting they may be agonal.

I think any animal with a gastric pH that is normal at 1 should have some pretty good intrinsic anti ulcer protection built into it.

Im not saying they do not occur under certain circumstances but ulcer sensitive sounds like a scare tactic from the makers of zantac

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Louise6732 — Tue, 29 Nov 2011 17:21:00 GMT

Wow, you know it's been a long day when you read the treatment of stasis in rabbits as 'Dom Perignon'

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Gillian Mostyn — Tue, 29 Nov 2011 13:34:39 GMT

Re: Cisepride, Ranitidine and Domperidone as prokinetics

shanley barber — Tue, 29 Nov 2011 12:08:59 GMT

[quote user="Gillian Mostyn"]

My priority is fluids - always get an iv catheter in! Then meloxicam, opioids and regular syringe feeding with oxbow critical care. Oh, and a really warm bed!

[/quote]

Hi Gillian,

Do you give fluids as a bolus or iv drip?

Thanks,

Shanley

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Marie Kubiak — Tue, 29 Nov 2011 12:01:38 GMT

I use ranitidine with domperidone in addition for advanced cases (though domperidone is only available as oral form which is not ideal for initial therapy). I prefer buprenoprhine for analgesia and am wary of using NSAIDs in ulcer-sensitive species with known dehydration and GI compromise.

Massive factors are GI stimulation by fibre and ongoing enteral and parenteral fluids. I'm sure in most cases bunnies would improve dramatically with just this supportive therapy. And of course deal with underlying cause of stasis.

Marie

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Gillian Mostyn — Mon, 28 Nov 2011 20:13:12 GMT

My priority is fluids - always get an iv catheter in! Then meloxicam, opioids and regular syringe feeding with oxbow critical care. Oh, and a really warm bed!

Re: Cisepride, Ranitidine and Domperidone as prokinetics

Mark Rowland — Mon, 28 Nov 2011 19:22:38 GMT

Cisapride, available through Summit Veterinary Pharmaceuticles

Tablets available now, Liquid next year hopefully.

Dont use Zantac much, my reasons can be found on this site,

Otherwise opiod and meloxicam like you

Goodluck